RBCto FFP ratio

[MAGNUM]

What is the PC:FFP ratio to use during a massive transfusion protocol?

[lalamb]

We've adopted 6 rbc: 4 ffp: 1 pl (got from a local university hosp)

Will post our sop's this weekend

[Mabel Adams]

There is ongoing research to determine this in the civilian population. The military proposes 1:1. I have also heard 2 RBC to 1 FFP. Key is start FFP early and keep giving it at least 2 RBC to one FFP and approaching 1 to 1 until we get better data. See the FFP transfusion guideline that came out a couple of years ago because the only indication for giving plasma that has good science behind it is in massive transfusion.

[Malcolm Needs ☆]

I think I am correct in saying (although I am quite prepared to be couontered on this one) that research is beginning to show that "one size does not fit all", and that it depends, to some extent, whether the injury is from blunt or sharp trauma; but this is only hearsay at this stage, so don't take it as the gospel truth.

[Deny Morlino]

I cannot remember where I read the information, but the military recommendations were determined not to be the best practice when examined in the civilian realm.

[Malcolm Needs ☆]

I think that was where I saw what I was talking about too Deny.

They have, more often, "sharp" injuries from bullets and blast injuries.

Civilians also have "sharp" injuries from bullets and knives (sadly), but also, more often, have "blunt" injuries from such things as car crashes, when they hit the windscreen, the steering wheel, etc.

I think that was it anyway?

[Deny Morlino]

Yes, that is the jist of what I remember. Sounds like the verdict is still out until further research is completed. I guess the final decision comes down to an individual one at each hospital based upon whatever works best for the stock available, medical director's comfort level, etc. I believe everyone is in agreement that there should be plasma infused whenever large amounts of packed cells are necessary. The ratio is up to the facility's discretion until better data is available.

[MAGNUM]

That is generally the idea that I get around here. We are currently proposing a 6:4:1:1 ratio, especially for our mothers that decide to bleed heavily. 6 RBC, 4 FFP, 1 PltPh, 1 Cryo.

[jmphil4]

Our facility uses 4:4 with platelets every other round and cryo as ordered.

[Maureen]

Our current policy states 6 RBC, 2 FFP, and one platelet; Cryo and Factor 7a on demand. We are in discussions to change to fewer RBCs, but don't yet have consensus on the new ratio. The OB/GYN population is the focus, but our new policy may distinguish between different patient population groups.

[tkakin]

a. MTP1 - 4 units PACKED RED BLOOD CELL’S 4 units of PLASMA and 1 apheresis PLATELET (upon initiation).

b. MTP2 - 4 units PACKED RED BLOOD CELL’S and 4 units of PLASMA

c. MTP3 - 4 units PACKED RED BLOOD CELL’S, 4 units of PLASMA, and 1 pre-pooled pack of CRYO

d. MTP’s will be ordered cycling through 1-3 until the MTP is canceled.

This is what we have chosen to do.

[Mabel Adams]

OBs will often be coming from a different starting point than traumas as they often run high levels of coag factors. Of course, if they are in DIC they will burn through those pretty fast. They are also more likely to be young and healthy and not on coumadin or plavix than the elderly fellow in a car wreck.

[SMILLER]

We have recently modified our massive transfusion policy to give sets of plasma in a one to one ratio. A set of coolers includes 5 RBCs, 5 Plasma, and one 5-pack platelets. Cryo is issued on request.

I, too, remember something published about plasma being most effective when given from the beginning if the patient is near bleeding out at some point.

Scott

Edited March 11, 2013 by SMILLER

[tbostock]

Yes, the jury is still out on the perfect ratio. Most studies suggest a 1:1 ratio is recommended, and there are a few studies showing that the early use of FFP has better outcomes for trauma.

I saw a really good web conference on MTPs and after giving all the information about the latest studies and which ratio is the best, the conclusion was:

"Nobody really knows, but just pick one and use it, because your patients will do better"

We use a 1:1 here, and have had some good success stories.

[Eagle Eye]

we use 1:1 ratio. (we are level I trauma center)

[Teristella]

Our docs want 1:1. We do 6RBC, 6FFP and a platelet, then a second batch of that with no platelet, then a third batch that is 4RBC, 4FFP and another platelet and cryo, if requested. Then back to the first batch.

[Juray]

We use 6RBC:4 FFP, platelet every other and Cryo as needed as well.

[aafrin]

We are in process of setting up this protocol, the HTC is still out on the ratio. Currently we issue RBCs, FFPs & Plts. as asked by the surgical/gynaec team. Do we need to have separate protocols for ob-gyn & other traumas (maybe RTAs) or one will be enough for both?

[tbostock]

We are in process of setting up this protocol, the HTC is still out on the ratio. Currently we issue RBCs, FFPs & Plts. as asked by the surgical/gynaec team. Do we need to have separate protocols for ob-gyn & other traumas (maybe RTAs) or one will be enough for both?

There is a lot of discussion on this as well, whether ob/gyn patients need a different ratio. These patients are usually not arriving coagulopathic, like some trauma patients are. But (in my opinion) a massive bleed is a massive bleed...you're bleeding out whole blood, you're going to need all of the components back. So for now we treat all massive bleeds the same with the 1:1 ratio until more definitive protocols come out for ob/gyn patients.

[Mabel Adams]

For those of you that include cryo automatically in your MTP packs, what prompted you to do so rather than wait for it to be ordered?  For the rest of you, why don't you include cryo?

 

Is there any argument for waiting to issue a platelet until the second or 3rd round?  I keep thinking of the first mechanical bleeding that they will fix by clamping off bleeding vessels and packing etc. and it seems like the plts can't help much until that is at least partly under control.  Plts are precious here and we are a long way from our supplier so I want to manage them well.

 

We need to go to a "pack" approach rather than just keeping ahead so I have to devise what will be in which packs.  When to insert plts and cryo are my big questions.

[tbostock]

 

For those of you that include cryo automatically in your MTP packs, what prompted you to do so rather than wait for it to be ordered?  For the rest of you, why don't you include cryo?

 

Is there any argument for waiting to issue a platelet until the second or 3rd round?  I keep thinking of the first mechanical bleeding that they will fix by clamping off bleeding vessels and packing etc. and it seems like the plts can't help much until that is at least partly under control.  Plts are precious here and we are a long way from our supplier so I want to manage them well.

 

We need to go to a "pack" approach rather than just keeping ahead so I have to devise what will be in which packs.  When to insert plts and cryo are my big questions.

 

For cryo: we made our MTP policy many years ago, when cryo was recommeded to be in the protocol. Since them, some studies have said it may not be necessary until very late in the bleeding episode. We left ours in because it seems to work, and we usually don't have a problem obtaining cryo from our blood supplier.

Platelets: we issue 1 unit of apheresis platelets after 8 PC, 8 FFP have been given. The only time we "move it up in the lineup" is if the patient has a very low platelet count or is on Plavix or another anti-platelet agent.

Send me your email in a private message and I will send you my policy and flowsheet that we use.

[Johnv]

We recently adopted the below guidelines to manage massive hemorrhage with OB patients.

 

California Maternal Quality Care Collaborative guidelines.

 

The guidelines lay out stages of increasing severity and the blood products to tx at each stage.  The Blood Bank supports our providers by ensuring RBCs, thawed plasma and at least 2 plateletpheresis are continuously available.

 

There are recommended transfusion ratios but as others have said, the different reasons for the massive hemorrhage dictate different responses.  I agree that the guidelines promulgated by the military for hemorrage during combat casualty care are unique for that specific circumstance and maynot work when applied to civilian settings.                                                                                                      

[AMcCord]

Mabel, we are also a long way from our supplier with limited platelets on hand. Our MTP says if the platelet count is less than 50,000 or patient is on Plavix, coumadin, etc., consider giving platelets. Cryo would be given based more on Fbg levels - again, we don't stock a lot of cryo.

[Dr. Pepper]

At our recent ASCLS-CNE meeting in Providence, there were a couple of lectures on this very subject. As several posters have noted, there is not a clear consensus as to the optimum component ratio. The point was made that just having a massive transfusion protocol in the first place to ensure a smooth, quickly available stream of components was very important, regardless of slight differences in the magic ratio. There was a great panel discussion at the MABB meeting a few weeks earlier looking back at the Boston Marathon bombing a year ago, where these protocols were put to the test. The speakers included a hospital safety officer, an ER nurse manager and a blood bank supervisor, from different Boston hospitals. The hospitals did a terrific job dealing with the victims, helped by several factors:

-The bombing occured around 2:45, so the hospitals took advantage of having both first and second shift staff available.

-The race finish already had medical staff, facilities and ambulances available.

-Several large, excellent hospitals were just minutes away.

-The patients started arriving at the hospitals within 15 minutes of the bombing. Some were in the OR within 10 minutes of arrival.

-These hospitals, being trauma centers, had massive transfusion policies in place, and were well practiced in their application.

The take home message was that this can happen anywhere, any time, and we should be ready, even if we work at smaller community hospitals (like mine) that have an ER but normally don't get the gory trauma patients.

[Rita]

_{Our current MTP is to give 3 units RBCs and 3 units FFP in each batch, with an apheresis platelet unit given with every other batch.  (1:1:1).  Cryo is given upon request.}